Provider Demographics
NPI:1356960223
Name:FLAKE, LESLIE BRETT
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:BRETT
Last Name:FLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:BRETT
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-524-2851
Mailing Address - Fax:
Practice Address - Street 1:2109 NAVAJO BLVD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-1822
Practice Address - Country:US
Practice Address - Phone:928-524-2851
Practice Address - Fax:928-524-2171
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ8203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program